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Zhu L, Wang Y, Song J, Sheng Z, Qi J, Li Y, Li G, Tang BZ. Two-Photon Absorption Aggregation-Induced Emission Luminogen/Paclitaxel Nanoparticles for Cancer Theranostics. ACS APPLIED MATERIALS & INTERFACES 2024; 16:27075-27086. [PMID: 38752796 DOI: 10.1021/acsami.4c02442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Multifaceted nanoplatforms integrating fluorescence imaging and chemotherapy have garnered acknowledgment for their potential potency in cancer diagnosis and simultaneous in situ therapy. However, some drawbacks remain for traditional organic photosensitizers, such as poor photostability, short excitation wavelength, and shallow penetration depth, which will greatly lower the chemotherapy treatment efficiency. Herein, we present lipid-encapsulated two-photon active aggregation-induced emission (AIE) luminogen and paclitaxel (PTX) nanoparticles (AIE@PTX NPs) with bright red fluorescence emission, excellent photostability, and good biocompatibility. The AIE@PTX NPs exhibit dual functionality as two-photon probes for visualizing blood vessels and tumor structures, achieving penetration depth up to 186 and 120 μm, respectively. Furthermore, the tumor growth of the HeLa-xenograft model can be effectively prohibited after the fluorescence imaging-guided and PTX-induced chemotherapy, which shows great potential in the clinical application of two-photon cell and tumor fluorescence imaging and cancer treatment.
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Affiliation(s)
- Liwei Zhu
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong 510515, China
- Innovation Research Center for AIE Pharmaceutical Biology, Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, Guangdong 511436, China
| | - Yiming Wang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing 100730, China
| | - Jiayi Song
- Innovation Research Center for AIE Pharmaceutical Biology, Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, Guangdong 511436, China
| | - Zonghai Sheng
- The Key Laboratory of Biomedical Imaging Science and System, Chinese Academy of Sciences, Shenzhen, Guangdong 518055, China
- Paul C. Lauterbur Research Center for Biomedical Imaging, Institute of Biomedical and Health Engineering, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong 518055, China
| | - Ji Qi
- State Key Laboratory of Medicinal Chemical Biology, Key Laboratory of Bioactive Materials, Ministry of Education, Interdisciplinary Center of Cell Response, and College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Ying Li
- Innovation Research Center for AIE Pharmaceutical Biology, Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, Guangdong 511436, China
| | - Guoxin Li
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Ben Zhong Tang
- School of Science and Engineering, Shenzhen Institute of Aggregate Science and Technology, The Chinese University of Hong Kong, Shenzhen (CUHK-Shenzhen), Shenzhen, Guangdong 518172, China
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Arikan M, Hargitai L, Binter T, Scheuba C, Riss P. In-vivo and ex-vivo parathyroid autofluorescence overlay imaging is equally feasible using two different wavelengths (785 nm vs. 805 nm). Curr Probl Surg 2024; 61:101443. [PMID: 38462311 DOI: 10.1016/j.cpsurg.2024.101443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/21/2023] [Accepted: 01/18/2024] [Indexed: 03/12/2024]
Affiliation(s)
- M Arikan
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
| | - L Hargitai
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - T Binter
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - C Scheuba
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - P Riss
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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Arikan M, Hegazy J, Mertlitsch S, Binter T, Hargitai L, Scheuba C, Riss P. Feasibility of Autofluorescence Using Overlay Imaging for the Detection of Parathyroid Glands: Defining Standards. Ann Surg Oncol 2024; 31:1116-1124. [PMID: 37957502 PMCID: PMC10761391 DOI: 10.1245/s10434-023-14552-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/22/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The aim of this study is to define standards for the use of near-infrared autofluorescence (NIRAF)-based overlay imaging via EleVision IR (Medtronic, Dublin, Ireland) and to evaluate its clinical applicability. PATIENTS AND METHODS This prospective study included 189 patients who had undergone open thyroid and/or parathyroid surgery and in whom EleVision IR was applied to visualize at least one parathyroid gland (PG) between January 2021 and May 2022 in a tertiary referral care center. Whether the PGs were first localized by the surgeon or by overlay imaging was noted. Handling of the device, application time and duration, distance, infrared intensity (IR%), and the angle of each measurement were analyzed. In thyroidectomies, the specimens were subsequently scanned for further PGs. NIRAF patterns and intensities were described. RESULTS Overall, 543 PGs were analyzed in 158 (83.6%) surgeries of thyroid glands (TGs) and in 49 (25.9%) surgeries for hyperparathyroidism. In 111 (58.7%) patients, identical numbers of PGs were detected by the surgeon and by overlay imaging. While a larger number of PGs was identified by the surgeon in 48 (25.4%) patients, overlay imaging served to detect more PGs in 30 (15.9%) cases. In four (2.1%) patients, PGs were visualized post-thyroidectomy due to their autofluorescence on the specimen. NIRAF-based overlay imaging was applied to depict the PGs early on after exposure by the surgeon. The ideal distance for the measurement ranged between 8 and 12 cm with an angle of 90° and a mean IR% of 34.5% (± 17.6). CONCLUSIONS Considering the standard operating procedures, NIRAF-based overlay imaging can be used as an adjunct tool for intraoperative localization.
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Affiliation(s)
- Melisa Arikan
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
| | - Josef Hegazy
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Sophie Mertlitsch
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Teresa Binter
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Lindsay Hargitai
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Scheuba
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Riss
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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Cottrill EE. Avoiding Complications of Thyroidectomy: Preservation of Parathyroid Glands. Otolaryngol Clin North Am 2024; 57:63-74. [PMID: 37659862 DOI: 10.1016/j.otc.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2023]
Abstract
Preservation of functional parathyroid glands during thyroidectomy and central neck surgery is crucial to avoid the common but serious complication of hypoparathyroidism. The first requirement is a solid foundational knowledge of anatomy and embryology which then enables the surgeon to use meticulous anticipatory dissection with identification and preservation of blood supply to the parathyroids. When preservation of blood supply is not possible, autotransplantation should be performed. New technologies harnessing the natural phenomenon of parathyroid autofluorescence to detect parathyroid tissue and indocyanine green to perform angiography may lead to improved outcomes with low risk to patients.
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Affiliation(s)
- Elizabeth E Cottrill
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, 925 Chestnut Street. 6th Floor, Philadelphia, PA 19107, USA.
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St Amour TC, Demarchi MS, Thomas G, Triponez F, Kiernan CM, Solόrzano CC. Educational Review: Intraoperative Parathyroid Fluorescence Detection Technology in Thyroid and Parathyroid Surgery. Ann Surg Oncol 2023; 30:973-993. [PMID: 36481865 DOI: 10.1245/s10434-022-12807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accurate parathyroid gland (PG) identification is a critical yet challenging component of cervical endocrine procedures. PGs possess strong near-infrared autofluorescence (NIRAF) compared with other tissues in the neck. This property has been harnessed by image- and probe-based near-infrared fluorescence detection systems, which have gained increasing popularity in clinical use for their ability to accurately aid in PG identification in a rapid, noninvasive, and cost-effective manner. All NIRAF technologies, however, cannot differentiate viable from devascularized PGs without the use of contrast enhancement. Here, we aim to provide an overview of the rapid evolution of these technologies and update the surgery community on the most recent advancements in the field. METHODS A PubMed literature review was performed using the key terms "parathyroid," "near-infrared," and "fluorescence." Recommendations regarding the use of these technologies in clinical practice were developed on the basis of the reviewed literature and in conjunction with expert surgeons' opinions. RESULTS The use of near-infrared fluorescence detection can be broadly categorized as (1) using parathyroid NIRAF to identify both healthy and diseased PGs, and (2) using contrast-enhanced (i.e., indocyanine green) near-infrared fluorescence to evaluate PG perfusion and viability. Each of these approaches possess unique advantages and disadvantages, and clinical trials are ongoing to better define their utility. CONCLUSIONS Near-infrared fluorescence detection offers the opportunity to improve our collective ability to identify and preserve PGs intraoperatively. While additional work is needed to propel this technology further, we hope this review will be valuable to the practicing surgeon.
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Affiliation(s)
- Taylor C St Amour
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Giju Thomas
- Department of Biomedical Engineering, Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, USA
| | - Frederic Triponez
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solόrzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. .,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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Baregamian N, Sekhar KR, Krystofiak ES, Vinogradova M, Thomas G, Mannoh E, Solórzano CC, Kiernan CM, Mahadevan-Jansen A, Abumrad N, Freeman ML, Weiss VL, Rathmell JC, Rathmell WK. Engineering functional 3-dimensional patient-derived endocrine organoids for broad multiplatform applications. Surgery 2023; 173:67-75. [PMID: 36400581 PMCID: PMC9939934 DOI: 10.1016/j.surg.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent advancements in 3-dimensional patient-derived organoid models have revolutionized the field of cancer biology. There is an urgent need for development of endocrine tumor organoid models for medullary thyroid carcinoma, adrenocortical carcinoma, papillary thyroid carcinoma, and a spectrum of benign hyperfunctioning parathyroid and adrenal neoplasms. We aimed to engineer functionally intact 3-dimensional endocrine patient-derived organoids to expand the in vitro and translational applications for the advancement of endocrine research. METHODS Using our recently developed fine needle aspiration-based methodology, we established patient-derived 3-dimensional endocrine organoid models using prospectively collected human papillary thyroid carcinoma (n = 6), medullary thyroid carcinoma (n = 3), adrenocortical carcinoma (n = 3), and parathyroid (n = 5). and adrenal (n = 5) neoplasms. Multiplatform analyses of endocrine patient-derived organoids and applications in oncoimmunology, near-infrared autofluorescence, and radiosensitization studies under 3-dimensional in vitro conditions were performed. RESULTS We have successfully modeled and analyzed the complex endocrine microenvironment for a spectrum of endocrine neoplasms in 3-dimensional culture. The endocrine patient-derived organoids recapitulated complex tumor microenvironment of endocrine neoplasms morphologically and functionally and maintained cytokine production and near-infrared autofluorescence properties. CONCLUSION Our novel engineered endocrine patient-derived organoid models of thyroid, parathyroid and adrenal neoplasms represent an exciting and elegant alternative to current limited 2-dimensional systems and afford future broad multiplatform in vitro and translational applications, including in endocrine oncoimmunology.
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Affiliation(s)
- Naira Baregamian
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Konjeti R Sekhar
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
| | - Emmanuel Mannoh
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
| | - Carmen C Solórzano
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Colleen M Kiernan
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Naji Abumrad
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael L Freeman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Vivian L Weiss
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey C Rathmell
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - W Kimryn Rathmell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Autofluorescence detection and co-axial projection for intraoperative localization of parathyroid gland. Biomed Eng Online 2022; 21:37. [PMID: 35710423 PMCID: PMC9205097 DOI: 10.1186/s12938-022-01004-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/23/2022] [Indexed: 12/24/2022] Open
Abstract
Background Near-infrared (NIR) autofluorescence detection is an effective method for identifying parathyroid glands (PGs) in thyroidectomy or parathyroidectomy. Fiber optical probes provide quantitative autofluorescence measurements for PG detection owing to its high sensitivity and high excitation light cut-off efficiency at a fixed detection distance. However, an optical fiber probe lacks the imaging capability and cannot map the autofluorescence distribution on top of normal tissue background. Therefore, there is a need for intraoperative mapping of PGs with high sensitivity and imaging resolution. Methods We have developed a fluorescence scanning and projection (FSP) system that combines a scanning probe and a co-axial projector for intraoperative localization and in situ display of PGs. Some of the key performance characteristics, including spatial resolution and sensitivity for detection, spatial resolution for imaging, dynamic time latency, and PG localization capability, are characterized and verified by benchtop experiments. Clinical utility of the system is simulated by a fluorescence-guided PG localization surgery on a tissue-simulating phantom and validated in an ex vivo experiment. Results The system is able to detect indocyanine green (ICG) solution of 5 pM at a high signal-to-noise ratio (SNR). Additionally, it has a maximal projection error of 0.92 mm, an averaged projection error of 0.5 ± 0.23 mm, and an imaging resolution of 748 μm at a working distance ranging from 35 to 55 cm. The dynamic testing yields a short latency of 153 ± 54 ms, allowing for intraoperative scanning on target tissue during a surgical intervention. The simulated fluorescence-guided PG localization surgery has validated the system’s capability to locate PG phantom with operating room ambient light interference. The simulation experiment on the PG phantom yields a position detection bias of 0.36 ± 0.17 mm, and an area intersection over unit (IoU) of 76.6% ± 6.4%. Fluorescence intensity attenuates exponentially with the thickness of covered tissue over the PG phantom, indicating the need to remove surrounding tissue in order to reveal the weak autofluorescence signal from PGs. The ex vivo experiment demonstrates the technical feasibility of the FSP system for intraoperative PG localization with accuracy. Conclusion We have developed a novel probe-based imaging and navigation system with high sensitivity for fluorescence detection, capability for fluorescence image reconstruction, multimodal image fusion and in situ PG display function. Our studies have demonstrated its clinical potential for intraoperative localization and in situ display of PGs in thyroidectomy or parathyroidectomy.
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Budner O, Cwalinski T, Skokowski J, Marano L, Resca L, Cwalina N, Kalinowski L, Hoveling R, Roviello F, Polom K. Methylene Blue Near-Infrared Fluorescence Imaging in Breast Cancer Sentinel Node Biopsy. Cancers (Basel) 2022; 14:cancers14071817. [PMID: 35406588 PMCID: PMC8997777 DOI: 10.3390/cancers14071817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/31/2022] [Indexed: 01/25/2023] Open
Abstract
Simple Summary Currently the gold standard for sentinel node biopsy in breast cancer patients is radioactive nanocolloid and a blue dye. In the age of fluorescence guided surgery new fluorophores are used and methylene blue presents some fluorescent properties. This study is the first in a clinical series presenting the possible use of methylene blue as a fluorescent dye for the identification of sentinel nodes in breast cancer sentinel node biopsy. We presented a feasibility of this new method and also in additional experiments because of the quenching effect limitation, found possible dilution of methylene blue presenting improved fluorescence. Abstract Introduction: Fluorescence-based navigation for breast cancer sentinel node biopsy is a novel method that uses indocyanine green as a fluorophore. However, methylene blue (MB) also has some fluorescent properties. This study is the first in a clinical series presenting the possible use of MB as a fluorescent dye for the identification of sentinel nodes in breast sentinel node biopsy. Material and methods: Forty-nine patients with breast cancer who underwent sentinel node biopsy procedures were enrolled in the study. All patients underwent standard simultaneous injection of nanocolloid and MB. We visualized and assessed the sentinel nodes and the lymphatic channels transcutaneously, with and without fluorescence, and calculated the signal-to-background ratio (SBR). We also analyzed the corresponding fluorescence intensity of various dilutions of MB. Results: In twenty-three patients (46.9%), the location of the sentinel node, or the end of the lymphatic path, was visible transcutaneously. The median SBR for transcutaneous sentinel node location was 1.69 (range 1.66–4.35). Lymphatic channels were visible under fluorescence in 14 patients (28.6%) prior to visualization by the naked eye, with an average SBR of 2.01 (range 1.14–5.6). The sentinel node was visible under fluorescence in 25 patients (51%). The median SBR for sentinel node visualization with MB fluorescence was 2.54 (range 1.34–6.86). Sentinel nodes were visualized faster under fluorescence during sentinel node preparation. Factors associated with the rate of visualization included diabetes (p = 0.001), neoadjuvant chemotherapy (p = 0.003), and multifocality (p = 0.004). The best fluorescence was obtained using 40 μM (0.0128 mg/mL) MB, but we also observed a clinically relevant dilution range between 20 μM (0.0064 mg/mL) and 100 μM (0.032 mg/mL). Conclusions: For the first time, we propose the clinical usage of MB as a fluorophore for fluorescence-guided sentinel node biopsy in breast cancer patients. The quenching effect of the dye may be the reason for its poor detection rate. Our analysis of different concentrations of MB suggests a need for a detailed clinical analysis to highlight the practical usefulness of the dye.
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Affiliation(s)
- Oliver Budner
- Frauenheilkunde und Geburtshilfe, HELIOS Kliniken Schwerin, Wissmarsche Street 393-397, 19-055 Schwerin, Germany;
| | - Tomasz Cwalinski
- Department of Surgical Oncology, Faculty of Medicine, Medical University of Gdansk, Marii Sklodowskiej-Curie Street 3a, 80-217 Gdansk, Poland; (T.C.); (J.S.)
| | - Jarosław Skokowski
- Department of Surgical Oncology, Faculty of Medicine, Medical University of Gdansk, Marii Sklodowskiej-Curie Street 3a, 80-217 Gdansk, Poland; (T.C.); (J.S.)
- Department of Medical Laboratory Diagnostics–Biobank Fahrenheit BBMRI.pl, Medical University of Gdansk, Debinki Street 7, 80-211 Gdańsk, Poland;
- Biobanking and Biomolecular Resources Research Infrastructure Poland (BBMRI.pl), 80-210 Gdańsk, Poland
| | - Luigi Marano
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci 16, 53-100 Siena, Italy; (L.M.); (L.R.); (F.R.)
| | - Luca Resca
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci 16, 53-100 Siena, Italy; (L.M.); (L.R.); (F.R.)
| | - Natalia Cwalina
- Department of Pediatrics Ascension, St. John Children’s Hospital, Detroit, MI 48236, USA;
| | - Leszek Kalinowski
- Department of Medical Laboratory Diagnostics–Biobank Fahrenheit BBMRI.pl, Medical University of Gdansk, Debinki Street 7, 80-211 Gdańsk, Poland;
- Biobanking and Biomolecular Resources Research Infrastructure Poland (BBMRI.pl), 80-210 Gdańsk, Poland
- BioTechMed/Department of Mechanics of Materials and Structures, Gdansk University of Technology, Gabriela Narutowicza Street 11/12, 80-233 Gdansk, Poland
| | - Richelle Hoveling
- Quest Medical Imagining, Industrieweg 41, 1775 PW Middenmeer, The Netherlands;
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci 16, 53-100 Siena, Italy; (L.M.); (L.R.); (F.R.)
| | - Karol Polom
- Department of Surgical Oncology, Faculty of Medicine, Medical University of Gdansk, Marii Sklodowskiej-Curie Street 3a, 80-217 Gdansk, Poland; (T.C.); (J.S.)
- Correspondence: ; Tel.: +48-58-349-31-90
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Cwalinski T, Skokowski J, Polom W, Marano L, Swierblewski M, Drucis K, Roviello G, Cwalina N, Kalinowski L, Roviello F, Polom K. Fluorescence Imaging Using Methylene Blue Sentinel Lymph Node Biopsy in Melanoma. Surg Innov 2022; 29:503-510. [DOI: 10.1177/15533506221074601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Fluorescence imaging of sentinel node biopsy in melanoma is a novel method. Both indocyanine green (ICG) and methylene blue (MB) have fluorescent properties. The aim of this study was to present, for the first time in a clinical series of patients, the possible usage of MB as a fluorescent dye for sentinel node biopsy during surgery for melanoma. Material and methods Twenty patients with skin melanoma, who were candidates for sentinel node biopsy were enrolled in our study. All patients underwent simultaneous use of standard nanocolloid and blue dye. Transcutaneous visualization of the sentinel node, visualization of lymphatic channels as well as sentinel node fluorescent visualization were all measured. We also performed calculations of Signal to Background ratios (SBR). Results In 15% (3/20) of patients, the fluorescent sentinel node was visible through the skin. The median SBR for the sentinel node visualization by fluorescence was 3.15 (range, 2.7–3.5). Lymphatic channels were visible in lymphatic tissue via fluorescence before visualization by the naked eye in 4 patients (20%). The median SBR ratio was 3.69 (range, 2.7–4.2). Sentinel nodes were visible by fluorescence in 13 cases (65%). The median SBR ratio was 2.49 (range, 1.5–5.7). No factors were found to be associated with fluorescent MB visualization of a sentinel node during biopsy. Conclusion This is the first clinical study presenting the usefulness of fluorescent sentinel node biopsy in melanoma patients using MB as a fluorophore. Further studies are necessary to provide methods for its’ clinical implementation.
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Affiliation(s)
- Tomasz Cwalinski
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Jarosław Skokowski
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
- Department of Medical Laboratory Diagnostics-Biobank, Medical University of Gdańsk, Gdańsk, Poland
- Biobanking and Biomolecular Resources Research Infrastructure Poland (BBMRI.PL), Gdańsk, Poland
| | - Wojciech Polom
- Department of Urology, Medical University of Gdansk, Gdansk, Poland
| | - Luigi Marano
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Maciej Swierblewski
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Kamil Drucis
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
| | | | - Natalia Cwalina
- Department of Pediatrics, Ascension St. John Children’s Hospital, Detroit, MI, USA
| | - Leszek Kalinowski
- Department of Medical Laboratory Diagnostics-Biobank, Medical University of Gdańsk, Gdańsk, Poland
- Biobanking and Biomolecular Resources Research Infrastructure Poland (BBMRI.PL), Gdańsk, Poland
- Department of Mechanics of Materials and Structures, Gdańsk University of Technology, Gdansk, Poland
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Karol Polom
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
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10
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Schouw HM, Huisman LA, Janssen YF, Slart RHJA, Borra RJH, Willemsen ATM, Brouwers AH, van Dijl JM, Dierckx RA, van Dam GM, Szymanski W, Boersma HH, Kruijff S. Targeted optical fluorescence imaging: a meta-narrative review and future perspectives. Eur J Nucl Med Mol Imaging 2021; 48:4272-4292. [PMID: 34633509 PMCID: PMC8566445 DOI: 10.1007/s00259-021-05504-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/23/2021] [Indexed: 12/27/2022]
Abstract
Purpose The aim of this review is to give an overview of the current status of targeted optical fluorescence imaging in the field of oncology, cardiovascular, infectious and inflammatory diseases to further promote clinical translation. Methods A meta-narrative approach was taken to systematically describe the relevant literature. Consecutively, each field was assigned a developmental stage regarding the clinical implementation of optical fluorescence imaging. Results Optical fluorescence imaging is leaning towards clinical implementation in gastrointestinal and head and neck cancers, closely followed by pulmonary, neuro, breast and gynaecological oncology. In cardiovascular and infectious disease, optical imaging is in a less advanced/proof of concept stage. Conclusion Targeted optical fluorescence imaging is rapidly evolving and expanding into the clinic, especially in the field of oncology. However, the imaging modality still has to overcome some major challenges before it can be part of the standard of care in the clinic, such as the provision of pivotal trial data. Intensive multidisciplinary (pre-)clinical joined forces are essential to overcome the delivery of such compelling phase III registration trial data and subsequent regulatory approval and reimbursement hurdles to advance clinical implementation of targeted optical fluorescence imaging as part of standard practice. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05504-y.
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Affiliation(s)
- H M Schouw
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - L A Huisman
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Y F Janssen
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - R H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - R J H Borra
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A T M Willemsen
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A H Brouwers
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - J M van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - R A Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Diagnostic Sciences, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
| | - G M van Dam
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,AxelaRx/TRACER Europe BV, Groningen, The Netherlands
| | - W Szymanski
- Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - H H Boersma
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre of Groningen, Groningen, The Netherlands
| | - S Kruijff
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands. .,Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
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11
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Law RH, Larrabee KA, Van Harn M, Singer MC. Parathyroid Gland Autofluorescence Characteristics in Patients With Primary Hyperparathyroidism. Laryngoscope 2021; 132:715-721. [PMID: 34612528 DOI: 10.1002/lary.29880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/18/2021] [Accepted: 09/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Near-infrared imaging for intraoperative parathyroid gland (PG) detection has recently commanded significant attention. The PTeye (Medtronic, Minneapolis, MN) is a probe-based system for near-infrared autofluorescent evaluation of PGs. This study was designed to evaluate the capabilities of the PTeye in the setting of surgery for primary hyperparathyroidism. STUDY DESIGN Prospective, Cohort study. METHODS This single-institution, prospective cohort study included all patients undergoing parathyroidectomy for primary hyperparathyroidism with presumed single gland disease from June 2020 to December 2020. Absolute intensity and intensity ratios, with the thyroid as the control tissue, were obtained for the adenoma, ipsilateral normal PG, and adjacent tissue. The ability of the PTeye to function when not in direct contact with tissue was measured. RESULTS Twenty-two patients were included. The median intensity ratio for the in situ adenomas was 4.38 (interquartile range [IQR]: 2.03-5.87), ipsilateral normal PGs 6.17 (IQR: 3.83-7.67), strap muscle 0.47 (IQR: 0.30-0.60), and fat 0.20 (IQR: 0.17-0.47). All normal PGs and 21/22 adenomas demonstrated autofluorescence above the detection threshold. The PTeye functioned at a maximum distance of separation of 10 mm through saline medium and 6 mm through clear solid medium. CONCLUSION This study confirms the PTeye's ability to recognize PGs with a high degree of precision. The device was found to function properly even with the probe not in direct contact with the tissue. Although adenomatous PGs appear to demonstrate altered autofluorescent properties from normal PGs, additional research is required to determine if these differences are clinically useful. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Richard H Law
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Katherine A Larrabee
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Meredith Van Harn
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Michael C Singer
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
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12
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Demarchi MS, Seeliger B, Lifante JC, Alesina PF, Triponez F. Fluorescence Image-Guided Surgery for Thyroid Cancer: Utility for Preventing Hypoparathyroidism. Cancers (Basel) 2021; 13:cancers13153792. [PMID: 34359693 PMCID: PMC8345196 DOI: 10.3390/cancers13153792] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/08/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Hypoparathyroidism is one of the most frequent complications of thyroid surgery, especially when associated with lymph node dissection in cases of thyroid cancer. Fluorescence-guided surgery is an emerging tool that appears to help reduce the rate of this complication. The present review aims to highlight the utility of fluorescence imaging in preserving parathyroid glands during thyroid cancer surgery. Methods: We performed a systematic review of the literature according to PRISMA guidelines to identify published studies on fluorescence-guided thyroid surgery with a particular focus on thyroid cancer. Articles were selected and analyzed per indication and type of surgery, autofluorescence or exogenous dye usage, and outcomes. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess the methodological quality of the included articles. Results: Twenty-five studies met the inclusion criteria, with three studies exclusively assessing patients with thyroid cancer. The remaining studies assessed mixed cohorts with thyroid cancer and other thyroid or parathyroid diseases. The majority of the papers support the potential benefit of fluorescence imaging in preserving parathyroid glands in thyroid surgery. Conclusions: Fluorescence-guided surgery is useful in the prevention of post-thyroidectomy hypoparathyroidism via enhanced early identification, visualization, and preservation of the parathyroid glands. These aspects are notably beneficial in cases of associated lymphadenectomy for thyroid cancer.
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Affiliation(s)
- Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland;
- Department of Endocrine Surgery, Lyon Sud University Hospitals, 69310 Pierre Benite, France;
| | - Barbara Seeliger
- IHU—Strasbourg, Institute of Image-Guided Surgery, 67091 Strasbourg CEDEX, France;
- IRCAD, Research Institute against Digestive Cancer, 67091 Strasbourg CEDEX, France
- Department of General, Digestive, and Endocrine Surgery, Strasbourg University Hospitals, 67091 Strasbourg CEDEX, France
- Department of Surgery and Center of Minimally Invasive Surgery, Evangelische Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, 45136 Essen, Germany;
| | - Jean-Christophe Lifante
- Department of Endocrine Surgery, Lyon Sud University Hospitals, 69310 Pierre Benite, France;
- Health Services and Performance Research Lab (EA 7425 HESPER), Université Claude Bernard Lyon 1, 69622 Lyon, France
| | - Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Evangelische Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, 45136 Essen, Germany;
- Department of Surgery, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland;
- Correspondence: ; Tel.: +41-(0)22-372-78-62
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13
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Near-infrared autofluorescence-based parathyroid glands identification in the thyroidectomy or parathyroidectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 407:491-499. [PMID: 34322746 DOI: 10.1007/s00423-021-02269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/06/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the diagnostic accuracy of near-infrared autofluorescence-based identification in the identification of parathyroid glands during thyroidectomy or parathyroidectomy. METHODS The clinical studies were retrieved from PubMed, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, SCOPUS, and Google Scholar. The study protocol was registered on Open Science Framework ( https://osf.io/um8rj/ ). The search period ranged from the date of each database's inception to May 2021. Cohort studies dealing with patients of whom parathyroid glands were detected by near-infrared autofluorescence and confirmed clinically or pathologically during thyroidectomy or parathyroidectomy were included. Editorials, letters, "how-I-do-it" descriptions, other site head and neck tumors, and articles with lack of diagnostic identification data were excluded. True positive, true negative, false positive, and false negative were extracted. The QUDAS ver. 2 was used to evaluate the methodological quality. RESULTS Seventeen studies with 1198 participants were evaluated in this analysis. Near-infrared autofluorescence-based identification of parathyroid glands showed a diagnostic odds ratio of 228.8759 (95% confidence interval, 134.1099; 390.6063). The area under the summary receiver operating characteristic curve was 0.967. The sensitivity, specificity, negative predictive value, and positive predictive value were 0.9693 (0.9491; 0.9816), 0.9248 (0.8885; 0.9499), 0.9517 (0.8981; 0.9778), and 0.9488 (0.9167; 0.9689), respectively. Subgroup analyses were performed to compare two autofluorescence detection methods, because there was high heterogeneity in the outcomes. The diagnostic accuracy was higher in probe-based detection than in image-based detection. CONCLUSIONS Near-infrared autofluorescence-based identification is valuable for identifying the parathyroid glands of patients during thyroidectomy or parathyroidectomy.
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14
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Demarchi MS, Karenovics W, Bédat B, De Vito C, Triponez F. Autofluorescence pattern of parathyroid adenomas. BJS Open 2021; 5:6137384. [PMID: 33609395 PMCID: PMC7893478 DOI: 10.1093/bjsopen/zraa047] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/11/2020] [Accepted: 11/05/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Primary hyperparathyroidism (pHPT) is a common endocrine pathology, and it is due to a single parathyroid adenoma in 80-85 per cent of patients. Near-infrared autofluorescence (NIRAF) has recently been used in endocrine surgery to help in the identification of parathyroid tissue, although there is currently no consensus on whether this technique can differentiate between normal and abnormal parathyroid glands. The aim of this study was to describe the autofluorescence pattern of parathyroid adenoma in pHPT. METHODS Between January and June 2019, patients with pHPT who underwent surgical treatment for parathyroid adenoma were enrolled. Parathyroid autofluorescence was measured. RESULTS Twenty-three patients with histologically confirmed parathyroid adenomas were included. Parathyroid adenomas showed a heterogeneous fluorescence pattern, and a well defined autofluorescent 'cap' region was observed in 17 of 23 specimens. This region was on average 28 per cent more fluorescent than the rest of the adenoma, and corresponded to a rim of normal histological parathyroid tissue (sensitivity and specificity 88 and 67 per cent respectively). After resection, all patients were treated successfully, with normal postoperative values of calcium and parathyroid hormone documented. CONCLUSION Parathyroid adenomas show a heterogeneous autofluorescence pattern. Using NIRAF imaging, the majority of specimens showed a well defined autofluorescent portion corresponding to a rim of normal parathyroid tissue. Further studies should be conducted to validate these findings.
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Affiliation(s)
- M S Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - W Karenovics
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - B Bédat
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - C De Vito
- Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
| | - F Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
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15
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Christison-Lagay E, Baertschiger RM. Management of Differentiated Thyroid Carcinoma in Pediatric Patients. Surg Oncol Clin N Am 2021; 30:235-251. [PMID: 33706898 DOI: 10.1016/j.soc.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Differentiated thyroid carcinoma in children is more likely to demonstrate nodal involvement and is associated with higher recurrence rates than seen in adults. Decisions regarding extent of surgical resection are based on clinical and radiologic features, cytology, and risk assessment. Total thyroidectomy and compartment-based resection of involved lymph node basins form the cornerstone of treatment. The use of molecular genetics to inform treatment strategies and the use of targeted therapies to unresectable progressive disease is evolving.
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Affiliation(s)
- Emily Christison-Lagay
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar Street, PO Box 208062, New Haven, CT, USA.
| | - Reto M Baertschiger
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Room 1524, 555 University Ave, Toronto, ON M5G 1X8, Canada
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16
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Wang B, Zhu CR, Liu H, Yao XM, Wu J. The Accuracy of Near Infrared Autofluorescence in Identifying Parathyroid Gland During Thyroid and Parathyroid Surgery: A Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:701253. [PMID: 34234746 PMCID: PMC8255791 DOI: 10.3389/fendo.2021.701253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/07/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE We aim to assess the accuracy of near infrared autofluorescence in identifying parathyroid gland during thyroid and parathyroid surgery. METHOD A systematic literature search was conducted by using PubMed, Embase, and the Cochrane Library electronic databases for studies that were published up to February 2021. The reference lists of the retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the combined variable. Publication bias in these studies was evaluated with the Deeks' funnel plots. RESULT A total of 24 studies involving 2,062 patients and 6,680 specimens were included for the meta-analysis. The overall combined sensitivity and specificity, and the area under curve of near infrared autofluorescence were 0.96, 0.96, and 0.99, respectively. Significant heterogeneities were presented (Sen: I2 = 87.97%, Spe: I2 = 65.38%). In the subgroup of thyroid surgery, the combined sensitivity and specificity, and the area under curve of near infrared autofluorescence was 0.98, 0.99, and 0.99, respectively, and the heterogeneities were moderate (Sen: I2 = 59.71%, Spe: I2 = 67.65%). CONCLUSION Near infrared autofluorescence is an excellent indicator for identifying parathyroid gland during thyroid and parathyroid surgery.
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Affiliation(s)
- Bin Wang
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Chun-Rong Zhu
- Department of Chemistry, School of Basic Medical Science, North Sichuan Medical College, Nanchong, China
| | - Hong Liu
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Xin-Min Yao
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Jian Wu
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
- *Correspondence: Jian Wu,
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17
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Abstract
OBJECTIVE With the recent approval of 2 NIRAF-based devices for label-free identification of PG by the Food and Drug Administration, it becomes crucial to educate the surgical community on the realistic scope of this emerging technology. Here, we have compiled a review of studies that utilize NIRAF and present a critical appraisal of this technique for intraoperative PG detection. BACKGROUND Failure to visualize PGs could lead to accidental damage/excision of healthy PGs or inability to localize diseased PGs, resulting in postsurgical complications. The discovery that PGs have NIRAF led to new avenues for intraoperatively identifying PGs with high accuracy in real-time. METHODS Using the following key terms: "parathyroid, near infrared, autofluorescence" in various search engines such as PubMed and Google Scholar, we identified various publications relevant to this review of NIRAF as a technique for PG identification. Articles were excluded if they focused solely on contrast agents, served as commentaries/overviews on NIRAF or were not written in English. RESULTS To date, studies have investigated the potential of NIRAF detection for (i) identifying PG tissues intraoperatively, (ii) locating PGs before or after dissection, (iii) distinguishing healthy from diseased PGs, and (iv) minimizing postoperative hypocalcemia after total thyroidectomy. CONCLUSIONS Because NIRAF-based identification of PG is noninvasive and label-free, the popularity of this approach has considerably surged. As the present limitations of various technologies capable of NIRAF detection are identified, we anticipate that newer device iterations will continue to be developed enhancing the current merits of these modalities to aid surgeons in identifying and preserving PGs. However, more concrete and long-term outcome studies with these modalities are essential to determine the impact of this technique on patient outcome and actual cost-benefits.
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18
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Cwalinski T, Polom W, Marano L, Roviello G, D’Angelo A, Cwalina N, Matuszewski M, Roviello F, Jaskiewicz J, Polom K. Methylene Blue-Current Knowledge, Fluorescent Properties, and Its Future Use. J Clin Med 2020; 9:jcm9113538. [PMID: 33147796 PMCID: PMC7693951 DOI: 10.3390/jcm9113538] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/24/2020] [Accepted: 10/30/2020] [Indexed: 12/14/2022] Open
Abstract
Methylene blue is a fluorescent dye discovered in 1876 and has since been used in different scientific fields. Only recently has methylene blue been used for intraoperative fluorescent imaging. Here, the authors review the emerging role of methylene blue, not only as a dye used in clinical practice, but also as a fluorophore in a surgical setting. We discuss the promising potential of methylene blue together with the challenges and limitations among specific surgical techniques. A literature review of PubMed and Medline was conducted based on the historical, current and future usage of methylene blue within the field of medicine. We reviewed not only the current usage of methylene blue, but we also tried to grasp its’ function as a fluorophore in five main domains. These domains include the near-infrared imaging visualization of ureters, parathyroid gland identification, pancreatic tumors imaging, detection of breast cancer tumor margins, as well as breast cancer sentinel node biopsy. Methylene blue is used in countless clinical procedures with a relatively low risk for patients. Usage of its fluorescent properties is still at an early stage and more pre-clinical, as well as clinical research, must be performed to fully understand its potentials and limitations.
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Affiliation(s)
- Tomasz Cwalinski
- Department of Surgical Oncology, Medical University of Gdansk, 80-214 Gdansk, Poland; (T.C.); (J.J.)
| | - Wojciech Polom
- Department of Urology, Medical University of Gdansk, 80-214 Gdansk, Poland; (W.P.); (M.M.)
| | - Luigi Marano
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53-100 Siena, Italy; (L.M.); (F.R.)
| | - Giandomenico Roviello
- Department of Health Sciences, University of Florence, viale Pieraccini 6, 50139 Florence, Italy;
| | - Alberto D’Angelo
- Department of Biology and Biochemistry, University of Bath, Bath BA2 7AY, UK;
| | - Natalia Cwalina
- Department of Pediatrics Ascension St. John Children’s Hospital, Detroit, MI 48236, USA;
| | - Marcin Matuszewski
- Department of Urology, Medical University of Gdansk, 80-214 Gdansk, Poland; (W.P.); (M.M.)
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53-100 Siena, Italy; (L.M.); (F.R.)
| | - Janusz Jaskiewicz
- Department of Surgical Oncology, Medical University of Gdansk, 80-214 Gdansk, Poland; (T.C.); (J.J.)
| | - Karol Polom
- Department of Surgical Oncology, Medical University of Gdansk, 80-214 Gdansk, Poland; (T.C.); (J.J.)
- Correspondence: ; Tel.: +48-583-493-190
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19
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Pediatric differentiated thyroid carcinoma: An update from the APSA Cancer Committee. J Pediatr Surg 2020; 55:2273-2283. [PMID: 32553450 DOI: 10.1016/j.jpedsurg.2020.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/04/2020] [Accepted: 05/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Differentiated thyroid carcinomas (DTCs) are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. METHODS This article reviews the recent literature describing surgical therapeutic approaches to pediatric DTC, associated complications, and long-term recurrence and survival outcomes. RESULTS Similar to adult thyroid cancers, pediatric DTCs are more common in females and are associated with thyroid nodules, family history of thyroid cancer, radiation exposure, iodine deficiency, autoimmune thyroid disease, and genetic syndromes. Management of thyroid cancers in children involves ultrasound imaging, fine needle aspiration, and surgical resection with treatment decisions based on clinical and radiological features, cytology and risk assessment. CONCLUSIONS Total thyroidectomy and compartment based resection of clinically involved lymph node basins form the cornerstone of treatment of DTC. There is an evolving literature regarding the use of molecular genetics to inform treatment strategies and the use of targeted therapies to treat iodine refractory and surgically unresectable progressive disease. TYPE OF STUDY Summary review. LEVEL OF EVIDENCE This is a review article of previously published Level 1-5 articles that includes expert opinion (Level 5).
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20
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Wong A, Wong JCY, Pandey PU, Wiseman SM. Novel techniques for intraoperative parathyroid gland identification: a comprehensive review. Expert Rev Endocrinol Metab 2020; 15:439-457. [PMID: 33074033 DOI: 10.1080/17446651.2020.1831913] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/30/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The parathyroid glands (PGs) are critical for calcium regulation and homeostasis. The preservation of PGs during neck surgery is crucial to avoid postoperative hypoparathyroidism. There are no existing guidelines for intraoperative PG identification, and the current approach relies heavily on the experience of the operating surgeon. A technique that accurately and rapidly identifies PGs would represent a useful intraoperative adjunct. AREAS COVERED This review aims to assess common dye and fluorescence-based PG imaging techniques and examine their utility for intraoperative PG identification. A literature search of published data on methylene blue (MB), indocyanine green (ICG) angiography, near-infrared autofluorescence (NIRAF), and the PGs between 1971 and 2020 was conducted on PubMed. EXPERT OPINION NIRAF and near-infrared (NIR) parathyroid angiography have emerged as promising and reliable techniques for intraoperative PG identification. NIRAF may aid with real-time identification of both normal and diseased PGs and reduce the risk of postoperative complications such as hypocalcemia. Further large prospective multicenter studies should be conducted in thyroid and parathyroid surgical patient populations to confirm the clinical efficacy of these intraoperative NIR-based PG detection techniques.
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Affiliation(s)
- Amanda Wong
- St. Paul's Hospital Department of Surgery, The University of British Columbia Department of Surgery , Vancouver, British Columbia, Canada
| | - Jovi C Y Wong
- St. Paul's Hospital Department of Surgery, The University of British Columbia Department of Surgery , Vancouver, British Columbia, Canada
| | - Prashant U Pandey
- Biomedical Engineering, University of British Columbia , Vancouver, British Columbia, Canada
| | - Sam M Wiseman
- St. Paul's Hospital Department of Surgery, The University of British Columbia Department of Surgery , Vancouver, British Columbia, Canada
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21
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Solórzano CC, Thomas G, Berber E, Wang TS, Randolph GW, Duh QY, Triponez F. Current state of intraoperative use of near infrared fluorescence for parathyroid identification and preservation. Surgery 2020; 169:868-878. [PMID: 33139065 DOI: 10.1016/j.surg.2020.09.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Finding and preserving normal parathyroid glands or localizing and removing diseased parathyroid glands are crucial steps to successful thyroid and parathyroid operations. Using near-infrared fluorescence detection to identify parathyroid glands during thyroid and parathyroid operations has lately gained widespread recognition, with 2 Food and Drug Administration-cleared devices currently in the market. We aim to update the endocrine surgery community on how near-infrared fluorescence detection can be most optimally used for rapid intraoperative parathyroid gland identification or preservation. METHODS A literature review was performed using the key terms: "parathyroid," "near infrared," and "fluorescence" in relevant search engines. Based on the reviewed literature and expert surgeons' opinions, recommendations were formulated for applying near-infrared fluorescence detection to identify or preserve parathyroid glands during cervical endocrine surgery. RESULTS The scope of near-infrared fluorescence detection can be broadly categorized into (1) using near-infrared auto-fluorescence to identify or locate both healthy and diseased parathyroid glands, and (2) using contrast-enhanced near-infrared fluorescence to evaluate parathyroid gland perfusion. The benefits and pitfalls for both near-infrared-based approaches are described herein. CONCLUSION Near-infrared fluorescence detection appears helpful for identification and likely preservation of parathyroid glands. We hope these recommendations will be valuable to the practicing endocrine surgeon as they consider incorporating these intraoperative adjuncts in their surgical practice.
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Affiliation(s)
- Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | - Tracy S Wang
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Gregory W Randolph
- Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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22
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Baudouin R, Simon F, Denoyelle F, Couloigner V, Irtan S. Lateral endoscopic parathyroidectomy in children. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 138:103-106. [PMID: 32798132 DOI: 10.1016/j.anorl.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Endoscopic thyroid and parathyroid surgery was first described by Gagner in 1996, and Henry subsequently proposed a lateral endoscopic approach in 1999. Technical progress in the fields of optics, endoscopy, digital imaging and laparoscopy has gradually enhanced the feasibility and clinical utility of this technique for the treatment of benign and malignant lesions. To date, published paediatric cases have only concerned thyroid surgery. In the light of two clinical cases, this article describes our lateral endoscopic approach applied to paediatric parathyroid surgery.
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Affiliation(s)
- R Baudouin
- Service d'ORL et chirurgie cervico-faciale pédiatrique, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France; Faculté de médecine, université de Paris, 15, rue de l'école de médecine, 75005 Paris, France.
| | - F Simon
- Service d'ORL et chirurgie cervico-faciale pédiatrique, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France; Faculté de médecine, université de Paris, 15, rue de l'école de médecine, 75005 Paris, France
| | - F Denoyelle
- Service d'ORL et chirurgie cervico-faciale pédiatrique, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France; Faculté de médecine, université de Paris, 15, rue de l'école de médecine, 75005 Paris, France
| | - V Couloigner
- Service d'ORL et chirurgie cervico-faciale pédiatrique, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France; Faculté de médecine, université de Paris, 15, rue de l'école de médecine, 75005 Paris, France
| | - S Irtan
- Service de chirurgie viscérale néonatale et pédiatrique, hôpital Trousseau, 26, avenue du docteur Arnold-Netter, 75012 Paris, France; Université Sorbonne Paris Cité, 91-105, boulevard de l'Hôpital, 75013 Paris, France
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23
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Wang B, Zhu CR, Liu H, Yao XM, Wu J. The inferior parathyroid glands preserved in site recover faster than the superior parathyroid glands preserved in site after thyroid surgery for carcinoma. Medicine (Baltimore) 2020; 99:e20886. [PMID: 32664081 PMCID: PMC7360264 DOI: 10.1097/md.0000000000020886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Due to the great difficulty in being preserved in site for the variable positions, the inferior parathyroid glands were advised to being routinely autotransplanted to prevent permanent hypoparathyroidism. The aim of this study was to compare the performance in the function of the superior parathyroid glands preserved in site with that of the inferior parathyroid glands preserved in site.We conducted a retrospective study including patients who underwent thyroid surgery for papillary thyroid carcinoma at our department between January 2014 and June 2018. According to the number and original position of the autoplastic parathyroid gland(s), patients were divided into group 1 (1 superior parathyroid gland), group 2 (1 inferior parathyroid glands), group 3 (1 superior parathyroid gland and 1 inferior parathyroid gland) and group 4 (2 inferior parathyroid glands). The postoperative complications and serum parathyroid hormone and calcium were analyzed.A total of 368 patients were included in the study, among them 27, 243, 40, and 58 patients were divided into group 1, group 2, group 3, and group 4, respectively. Compared with those in group 2, the serum parathyroid hormones were higher at 1 week (2.98 ± 1.52 vs 2.42 ± 0.89, P = .049) and 2 weeks (3.49 ± 1.42 vs 2.8 ± 0.81, P = .019) postoperatively in group 1. There was also significantly different in the serum parathyroid hormone at 2 weeks postoperatively between group 3 and group 4 (2.95 ± 0.98 vs 2.58 ± 0.82, P = .047).The inferior parathyroid glands preserved in site recover faster than the superior parathyroid glands preserved in site.
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Affiliation(s)
- Bin Wang
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu
| | - Chun-Rong Zhu
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan
- Department of Chemistry, School of Basic Medical Science, North Sichuan Medical College, Nanchong, China
| | - Hong Liu
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu
| | - Xin-Min Yao
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu
| | - Jian Wu
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu
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24
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Idogawa H, Sakashita T, Yagi T, Segawa K, Homma A. Pathological evaluation of the accuracy of a fluorescence spectroscopy system for detecting parathyroid glands. Eur Arch Otorhinolaryngol 2020; 277:3145-3147. [PMID: 32377853 DOI: 10.1007/s00405-020-06011-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/24/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE A fluorescence-based technique for the detection of parathyroid glands (PGs) intraoperatively was previously reported. The technique was based on the phenomenon in which PGs emit autofluorescence when exposed to near-infrared light and we undertook an evaluation to consider the pathological accuracy of the method. METHODS The study comprised 17 patients (18 specimens) who underwent thyroid surgery at Kushiro City General Hospital between November 2018 and June 2019. We searched for PGs intraoperatively using a fluorescence spectroscopy system and evaluated the pathological accuracy of the system. We statistically evaluated the clinical factors associated with the accuracy of the system, including age, gender, body mass index, laterality, disease state, renal function, and comorbidity. RESULTS Eighteen specimens were evaluated pathologically, with 13 specimens confirmed as PGs. These were evaluated as "true positive," giving a positive predictive value of 72.2% (13/18). Among the false-negative cases, one specimen was a metastatic lymph node in a patient with papillary thyroid carcinoma. There was a significant difference in the true-positive rates between malignant (25%) and benign (85.7%) disease (P = 0.044). CONCLUSION We consider that this technique is useful, however, we have to exercise care in malignant cases as the true-positive rate may be low.
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Affiliation(s)
- Hiroshi Idogawa
- Department of Otolaryngology-Head and Neck Surgery, Kushiro City General Hospital, 1-12, Shunkodai, Kushiro, 085-0822, Japan
| | - Tomohiro Sakashita
- Department of Otolaryngology-Head and Neck Surgery, Kushiro City General Hospital, 1-12, Shunkodai, Kushiro, 085-0822, Japan.
| | - Takeki Yagi
- Department of Otolaryngology-Head and Neck Surgery, Kushiro City General Hospital, 1-12, Shunkodai, Kushiro, 085-0822, Japan
| | - Keiko Segawa
- Department of Surgical Pathology, Kushiro City General Hospital, 1-12, Shunkodai, Kushiro, 085-0822, Japan
| | - Akihiro Homma
- Department of Otolaryngology-Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan
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25
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Recent Advances and the Potential for Clinical Use of Autofluorescence Detection of Extra-Ophthalmic Tissues. Molecules 2020; 25:molecules25092095. [PMID: 32365790 PMCID: PMC7248908 DOI: 10.3390/molecules25092095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023] Open
Abstract
The autofluorescence (AF) characteristics of endogenous fluorophores allow the label-free assessment and visualization of cells and tissues of the human body. While AF imaging (AFI) is well-established in ophthalmology, its clinical applications are steadily expanding to other disciplines. This review summarizes clinical advances of AF techniques published during the past decade. A systematic search of the MEDLINE database and Cochrane Library databases was performed to identify clinical AF studies in extra-ophthalmic tissues. In total, 1097 articles were identified, of which 113 from internal medicine, surgery, oral medicine, and dermatology were reviewed. While comparable technological standards exist in diabetology and cardiology, in all other disciplines, comparability between studies is limited due to the number of differing AF techniques and non-standardized imaging and data analysis. Clear evidence was found for skin AF as a surrogate for blood glucose homeostasis or cardiovascular risk grading. In thyroid surgery, foremost, less experienced surgeons may benefit from the AF-guided intraoperative separation of parathyroid from thyroid tissue. There is a growing interest in AF techniques in clinical disciplines, and promising advances have been made during the past decade. However, further research and development are mandatory to overcome the existing limitations and to maximize the clinical benefits.
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26
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Baj J, Sitarz R, Łokaj M, Forma A, Czeczelewski M, Maani A, Garruti G. Preoperative and Intraoperative Methods of Parathyroid Gland Localization and the Diagnosis of Parathyroid Adenomas. Molecules 2020; 25:E1724. [PMID: 32283730 PMCID: PMC7181220 DOI: 10.3390/molecules25071724] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023] Open
Abstract
Accurate pre-operative determination of parathyroid glands localization is critical in the selection of minimally invasive parathyroidectomy as a surgical treatment approach in patients with primary hyperparathyroidism (PHPT). Its importance cannot be overemphasized as it helps to minimize the harmful side effects associated with damage to the parathyroid glands such as in hypocalcemia, severe hemorrhage or recurrent laryngeal nerve dysfunction. Preoperative and intraoperative methods decrease the incidence of mistakenly injuring the parathyroid glands and allow for the timely diagnosis of various abnormalities, including parathyroid adenomas. This article reviews 139 studies conducted between 1970 and 2020 (49 years). Studies that were reviewed focused on several techniques including application of carbon nanoparticles, carbon nanoparticles with technetium sestamibi (99m Tc-MIBI), Raman spectroscopy, near-infrared autofluorescence, dynamic optical contrast imaging, laser speckle contrast imaging, shear wave elastography, and indocyanine green to test their potential in providing proper parathyroid glands' localization. Apart from reviewing the aforementioned techniques, this study focused on the applications that helped in the detection of parathyroid adenomas. Results suggest that applying all the reviewed techniques significantly improves the possibility of providing proper localization of parathyroid glands, and the application of indocyanine green has proven to be the 'ideal' approach for the diagnosis of parathyroid adenomas.
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Affiliation(s)
- Jacek Baj
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Robert Sitarz
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
- Department of Surgery, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Marek Łokaj
- Department of Surgery, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Alicja Forma
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Marcin Czeczelewski
- Chair and Department of Forensic Medicine, Medical University of Lublin, 20-950 Lublin, Poland;
| | - Amr Maani
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Gabriella Garruti
- Section of Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro” Medical School, 70124 Bari, Italy;
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